HeartMath^® De-Stress Workshop™ Qualified Instructor Application

1. Which training dates do you want to attend?

Instructor Information

1. First Name
2. Last Name
3. Title/Affiliation to Nonprofit
4. Your Profession

Sponsoring Organization Contact Information

1. Organization Name
2. Address
3. City
4. State
5. Zip Code
6. Business Phone
7. Web Site
8. Fax
9. E-mail Address

Instructor Contact Information

1. Home Address
2. City
3. State
4. Zip Code
5. Home Phone
6. Cell Phone
7. Web Site
8. E-mail Address

Ship to Address

Please indicate where you would like to receive training materials:

1. Same as Instructor’s Home Address
2. Same as Organization’s Address
3. Other (please provide address below)

General Information

1. How did you hear about HeartMath?

Do you have an emWave^® Desktop?

1. Yes No

What Operating System do you use?

1. PC Mac

Do you have an emWave Personal Stress Reliever^®?

1. Yes No

1. What HeartMath products or services have you used?

   Please include HeartMath workshops or seminars you may have attended.

1. What professional training have you received?

   Please include degrees, certifications and licenses held and dates completed.

1. Please describe the trainings you have presented.

1. Why do you want to become a qualified instructor for the De-Stress Workshop?

1. To whom will you be presenting the workshop?

1. Estimate the number of people you will serve with this program over the next year.

1. Include a brief summary of professional experience (500 characters max.)

1. Upon completion of the program you will receive a Certificate of Completion. Please indicate how you prefer your name to appear on the license certificate (e.g. Janet Connor, Ph.D.)

Reference Contact

Please list contact information for two references:

Reference Contact #1

1. Name
2. Phone
3. Organization & Title

Reference Contact #2

1. Name
2. Phone
3. Organization & Title